Tag: patient experience

I’d like to re-start blogging by sharing with you what shows up for me as a most enlightening and inspiring tale of leadership, customer-centricity, and organisational transformation. Let’s start.

I encourage you to listen to Dr David Feinberg tell his story

When Dr. David Feinberg arrived at UCLA’s executive suite, the majority of patients said they wouldn’t recommend the hospital to a friend — even if the hospital saved their lives. He went on to transform the organisation. How did he go about it? I’ve listened to his story and I say it is well worth listening to him because it is a story from the man who has lived the experience – not an academic, not a guru, not a consultancy…..

You can find out by listening to Dr Feinberg share his story. If you are not in a position to listen to his story then I have extracted the following highlights for you and me. Please note this post is long and it will reward only those with a genuine interest in leadership, customer-centricity, and organisational transformation. Let’s start.

He started by talking with and listening to customers every day and in person

“What I did, and what I have done every day over the last six years, I went up and met with our patients… I knocked on the door ‘Hi, I’m Dr Feinberg. Can I sit down?’ And I’d ask how the care was, how were things going. I did this for 2 to 3 hours every day for the first three months.”

What did Dr Feinberg learn from his talks with patients? He says he learnt two important lessons:

1. “At UCLA we perform miracles…. We do very high end high touch stuff”

2. “The compassionate side we were missing. No-one [patients] knew who was in charge of their care. Nobody knew what was coming next in their care…… hot food that was never hot, cold fold that was never cold. The place was dirty. Two thirds, despite us saving their lives, would not refer us to a friend.”

Was Dr Feinberg or the UCLA hospital system under any pressure to make any changes? “After eight days in the job, US News and World Report changed our ranking from 5th best to the 3rd best hospital.”

So why did Dr Feinberg end up taking a stand, being a leader, making changes and eventually transforming the organisation? On the very day that UCLA moved from 5th best to 3rd best he met a patient who told him that he could not get a bed pan. As Dr Feinberg says, when you need a bad pen you need a bed pan!

Dr Feinberg comes face to face with complacency and ridicule

“I talked to the team. Why do we not have enough wheelchairs and bed pans?”

Their response? “We can never be like those other places. We are an academic medical centre, we are about curing ….. these are minor issues.”

Dr Feinberg goes on to shares his encounter with a 16 year old girl dying of leukaemia:

“Met a sixteen year old girl dying of leukaemia. The tv did not work in her room… did not have lot of family.. soap operas were her connection to the outside world… developmental age of 12 due to illness. Went back to the executive suite ‘We got to get the tv fixed upstairs! They laughed at me and gave me a screwdriver.”

Exercising leadership and focusing on patient

“After about three months of doing this I said ‘We’re going to focus on the patient. We’re going to take are of patients the way I want my family to be cared for.'”

How did the rest of the team react to this stance, this declaration, this exercise of leadership? “People looked at me as if I was crazy and said ‘We should have never hired a psychiatrist… We’ve done customer training before, I’ve got the coffee mug. Why are we doing this again?'”

Focusing on one thing and exercising leadership by living the stand

Faced with this resistance and being in the role only as an interim, Dr Feinberg sought advice. “Mentor of mine told me stay focused. Stay focused on one thing. And that can be something you can drive through the organisation.”

What did Dr Feinberg do? He lived his stand, he became a living example of the desired commitment and behaviours. “I got the girl’s tv fixed. I helped patients to the commode. I went down to the pharmacy to get meds. I pushed patients in wheelchairs. And I still pick up trash all the time.”

Results: great accomplishment or cream of the crap?

“Went from 38th percentile to 99th percentile on question of would you refer us to a friend. Six thousand hospitals in the USA, we’re ranked at the very top…… academic-teaching hospitals, we’re ranked No1 on would you refer us to a friend.”

When I heard this, this statistic showed up as a fantastic accomplishment. What does Dr Feinberg say about this accomplishment?

“That actually sucks. To get 99th percentile on patient satisfaction, in my industry, 85 out of 100 checked the box. So, I say we are the cream of the crap. We now have brand new buildings. We have got great structure and customer service programmes that we developed over the last five or six years to sustain this. We’re making lots of money. We have the best doctors and nurses in the country. And yet out of the last 100 people we’ve taken care of, fifteen of them would not refer us to a friend.

By definition these fifteen people are somebody’s mom, somebody’s brother, a child, a co-worker, a parent etc. Occasionally you meet people with unrealistic expectations maybe 1 or 2 out of the fifteen, but the other thirteen or fourteen people are like you and me..

My journey hasn’t stopped at all…. Still have a long way to go to get 99 out of 100 people, not 99th percentile, telling us how great we’ve done. “

On turning a vacuous mission statement into a meaningful-compelling one

“About five years ago … I don’t know what our mission statement was. It was something like ‘We’re UCLA. aren’t you lucky you get to see us’ cause that’s how we acted. We changed that ‘Our purpose is to heal mankind one patient at a time. And we do that by alleviating suffering, promoting health, and delivering acts of kindness.”

Is the reference to acts of kindness just marketing or CEO fluff? Dr Feinberg shared the example of a grandmother dying of cancer whilst her daughter was delivering in San Francisco. The nursing staff, without asking for permission, flew in the daughter so that the granddaughter could be held by grandmother before she passed away.

What was the business impact of this mission? Dr Feinberg mentions that UCLA has the ability to recruit and retain the best. And “deliver incredible volumes [of patients] to our institution”.

“I really believe if we get it right in the room with the patient, that everything else will take care of itself….. The way we thought at UCLA … the illness didn’t begin until they got to us. Really the illness begins after that family when mom might have cancer or when the elderly parent falls. I think it’s our job to engage with our patients in a way that we connect with them from the second they call us until they are back in girls scouts, back doing their work, or back living independently.

What we had done historically, in healthcare, is create times when you came to see us in the medical profession and we used you as inventory and lined you up. And it was what we would call provider centric instead of patient centric.

So we are changing our waiting rooms…. Patients who come to see us will have a smart card on their dashboard. So when they come to see us, we know we have four minutes to get ready before they arrive upstairs. And we’ll have the room ready before they get upstairs. And the waiting room will be for the doctors waiting to see the patient. Patient will be in the room.

When you just flip it and take it as the view of the patient it becomes really clear what you need to do.

When we have clinic retreats now, when we talk with leadership, we never start a meeting without a patient being present and holding us to accountable.”

Breakdowns: what happens when staff members hear directly from the customer?

The access to breakthroughs is provided by breakdowns. Dr Feinberg seems to have an intuitive understanding of this. In his talk he tells the story of 63 year old woman who turns up at UCLA at 2am in the morning. Here is the sequence of events:

2am – she turns up at emergency centre with abdominal pain. Scans are done on her. She is told that she needs to have her gall bladder removed. Husband is sent home and asked to come back for 6am. He leaves the hospital taking his wife’s purse and coat.

Medical staff re-read the scans, determine the woman is OK and tell her she can go home. She asks for a taxi voucher to get home (9 miles away) as husband has already left with her purse. She is told she doesn’t qualify. She finds a few dollars in her sweater and takes taxi part way home.

Husband meets her half way and drives her home. On reaching home, phone rings and UCLA asks her to come back in for surgery: UCLA have re-read her scan and determined this is an emergency. Husband and wife drive back to UCLA where her gall bladder is successfully removed.

In recovery, she is asked to sign a consent form – to be tested for HIV. Why? UCLA made mistake: used a syringe on her that they had used on a previous patient. Test comes back negative.

What does Dr Feinberg have to say on the matter?

“Talk about this a provider centric way… we did a phenomenal job! We took out her gall bladder successfully. We didn’t give her an infection. But if you thought about that as your mom, how pissed off are you?

I brought together everybody who had anything to do with her care: valet parking, emergency room, transporters, social work, OR staff, ER staff, everyone from billing, collecting and IT….. She came in and told her story… She tells it a lot better than I do, there’s a lot more feeling….

What happens when these people hear the actual patient? Incredible things happen in the organisation. Nobody will ask twice for a taxi voucher at UCLA again. We had all kinds of policies about how not to use syringes twice….But now because her story is connected to it, I go to bed at night really believing that there’s a greater chance that we’re not going to mess up. There’s a real sense that that person and that face is connected to everything we do.

Did Dr Feinberg follow best practice: devise a strategy, follow a formulaic model, develop plans and then execute?

“The journey has included a lot of changes and it sounds like we know what we were doing. I want to tell you that I had no idea what I was doing. I do know that we were focussed on getting it right for that very next patient”

Other lessons

Dr Feinberg points out the critical importance of:

1. selecting the right talent in the right way. In particular, he points out the need to recruit people who are both competent AND have the service mindset;

2. codifying and communicating the expected behaviours during the induction (on boarding) process; and

3. rigorously measuring and communicating performance against these behaviours.

On the second point, he states that UCLA clearly spell out and train their staff on:

– how to go in and introduce yourself to a patients;

– how you ask permission before you touch patients;

– how you explain what is coming next;

– how you tell patients when you’re leaving and do they have any questions.

“In the past it was you’re a nurse, your a doctor come on in and take care of the patient. No patient at UCLA gets touched without permission, everybody introduces themselves, everybody gives their name and cellphone number.

I give my cellphone number out probably 100 times a day to patients and say call me 24 hours a day if there’s anything that I can do to assist you and your family.

We don’t always get it right, there are plenty of challenges that face us. I do believe being centred around the patient is the right way to go.”

Are we living in an age of inhumanity, hypocrisy, and moral bankruptcy?

It occurs to me that we live in an age of greed, inhumanity, hypocrisy, and moral bankruptcy. I say that this inhumanity and moral bankruptcy both enables and is enabled by the doctrine of management. I say it is folly of the highest degree to be applying the practices of scientific management in the 21st century. I say it is folly to expect an authentic customer-orientation when the name of the game is greed: making as much money as possible, today, irrespective of the cost as long as the cost is paid by someone else – today or tomorrow.

I am clear that the cancer of greed, inhumanity, hypocrisy, and moral bankruptcy has spread from the world of big business into just about every institution – the government, the civil service, the police, the NHS – in the UK. And into society itself. Today we got a wake-up call, will we listen?

The NHS Mid Staff scandal: 400 – 1,200 human beings died as a result of poor care over 50 months

Let’s first get present to what has occurred. According to the Guardian:

“An estimated 400-1,200 patients died as a result of poor care over the 50 months between January 2005 and March 2009 at Stafford hospital, a small district general hospital in Staffordshire. The report being published on 6 February 2013 of the public inquiry chaired by Robert Francis QC will be the fifth official report into the scandal since 2009, and Francis’s second into the hospital’s failings.

The often horrifying evidence that has emerged means “Mid Staffs” has become a byword for NHS care at its most negligent. It is often described as the worst hospital care scandal of recent times. In 2009 Sir Ian Kennedy, the chairman of the Healthcare Commission, the regulator of NHS care standards at the time, said it was the most shocking scandal he had investigated.”

What was the customer experience like?

“You only had to open a ward door at the hospital to smell the stench of urine, hear patients screaming in pain and see staff being bullied, and know that the care was appalling.

My mum died in that hospital terrified of the people that should have cared for her. She was recovering from an operation when nurses dropped her and hurt her. After four days in the hospital I could see that unless I was there to feed and wash her she would have just been left without care. Even with me at her side, a nurse refused to administer a life-saving drug. My mother died a few hours later, eight weeks after going into hospital. She was a strong woman. She should never have died in there. In 2002, Dr Peter Daggett, a former senior doctor at the hospital, had already raised concerns that the hospital was out of control…”

Does this sound dramatic to you? Not to me. My father went to hospital with a stroke. Like Julie, I found myself at the hospital feeding and taking care of my father. I had to threaten to go to the media to get the care that my father needed.

What led to such shocking disregard for patients – their humanity, their wellbeing?

As one trained in systems thinking and modeling it is rather easy to figure out the what kind of system structure would cause that which occurred:

– start with an inefficient system that is just about coping with existing demand;

– demand instant improvements which are most likely to be made through headcount reductions and other simplistic cost reduction measures;

– apply pressure through targets and leave targets open to being gamed;

– introduce a management philosophy and practices that are detrimental to an ethos of care, of public service;

– ensure that there is political pressure to provide a misleading/flattering image of the beneficial effects (better patient care, more efficient NHS) of the cuts and changes to the NHS.

Viola, you have a system that will look healthily on the surface, whilst killing customers – the patients in this case.

What does Julie Bailey say?

“This shift away from patient care started to happened under the Labour government. It destroyed the culture of care in the NHS by replacing it with a top-down, target-driven culture. Former health secretary Andy Burnham contributed to this. He wouldn’t even meet the grieving relatives at Stafford hospital and he only gave us a secret inquiry so that the NHS’s dirty linen wouldn’t be aired in public.

In 2007, I set up Cure the NHS, a patient campaign group formed to highlight the poor care at Stafford Hospital, following the death of my 86-year-old mother, Bella, after she went in for a routine hernia operation. While we were campaigning outside, Peter Carter, head of the Royal College of Nursing, visited Stafford hospital. He wrote to our local newspapers saying what a good hospital it was, with good management and good staff...”

This post follows on from the previous one – if you have not read it then you may wish to do so, as this post continues the story, the conversation.

Trust – I put my life in the hands of ‘others’

I awaken and notice that I am back in the day ward, what happened, what am I doing here? Confusion. My last memory is of being in the ‘operating theatre’: the nurses are hooking me up to equipment and assuring me that they will be monitoring my vital signs throughout the procedure. The Consultant inserts a needle into my hand, the sedative flows I can feel that it is warm. Now I am awake, here in this ward.

The nurse offers me a tea and sandwiches, I refuse. She gently and confidently tells me that the right thing to do is to take the tea and sandwiches. I agree – she comes across as she knows what she is doing and she is doing it out of care for me. After finishing the ‘meal’ and the paperwork, she tells me someone will be along soon to take me to another ward until my wife can come and collect me.

As I am wheeled along to the other ward I reflect on what happened today and has happened before. How many times have I put my life at risk – in the hands of the medical profession? It occurs to me that trust is present between me, the doctors and the nurses. I trust that they will act in my best interests, to take care of me, to safeguard my life by doing the right thing. I can think of two instances where the medical profession saved my life: at the age of 8 when I walked into the path of van and then in my mid-20s when I had a blockage in an artery ……

What is the bedrock of this trust? I am of the view that the medical profession is bound by the prime directive: do no harm.I am convinced that the doctors and nurses are here for me – to serve me, to cater for my needs, my welfare – and not the other way around. I believe that there are rigorous standards in place to ensure competence – these folks know what they are doing, they haven’t just walked off the street. What would happen if this trust was eroded? Would we, here in the UK, end up in the same place as the USA? Highly likely. Trust is THE lubricant of friction free relationships between human beings. Trust is what makes all forms of social organisation possible.

Now compare this with the business world. What is the prime directive? Can you and I honestly say that the prime directive is to do no harm to customers? What about the design of the business system? Is ‘business’ there to serve me and my needs or is it there to find means to sell stuff to anyone who can be persuaded to buy it? Is it somewhere in the middle? What about competence? How sure can you and I be that the business folks we depend on are competent? I know of a bank where the vast majority of customer services staff cannot accurately answer the top 10 frequently asked questions. And then are the customer facing staff in stores – most of them do not have the requisite product knowledge nor the skills to listen to / talk with customers.

Care: the difference that makes all the difference?

The Consultant telling the nurse that he was going to give me a sedative as that was the right thing to do. And instructing her to find me a bed showed up as care – care for me.

The nurse ringing around, finding a bed, coming back to tell me with a smile in her being, showed up as care – care for me, for my well being.

The Consultant and the team rearranging the operating schedule to put me lower on the list – as I was in lots of pain and not ready to be ‘operated’ on – showed up as care, care for me.

The nurses talking to me, explaining what was about to happen, pointing out that they were hooking me up to equipment to monitor my vital signs throughout the procedure showed up as care – care for me.

The nurse offering/encouraging me to have that tea and sandwich after the ‘operation’ showed up as act of care – care for me.

The trainee nurse coming up every so often to measure my blood pressure showed up as care – care for me.

The nurses on the receiving ward who got that I was not lucid, who first found me chair to sit in and then later moved me to the bed (when it became available) and then put blanket on me showed care – care for me!

What I am present to is the kindness/care of strangers, the kindness of my fellow human beings, the kindness of the medical professionals – at my GP’s surgery and at Heatherwood Hospital. What showed up in my experience was caring and competence. Caring is not enough it requires competence. Competence is not enough, it requires authentic caring for the other as fellow human being.I say that if you care then you make sure that you do all that you need to do to be competent. Put differently, ensuring competence is a key act of caring and if incompetence is present then that shows a lack of caring, indifference.

Authentic caring involves doing what is right including going against the wishes of the customer if that is the right thing to do. After the procedure, when I woke up I was ready to get dressed and literally walk home – I felt that fine. I told the nurses that I would walk to the other ward. I asked the nurses to leave him outside on the lawn until my wife turned up so that I would not take up a bed that someone else needed. They ignored me. Why? They had a better map of the situation – they knew that I was not lucid, not fit to make decisions, not fit to look after myself.

One other thought occurs to me, the level of caring varied from one person to another. Put differently, caring did not show up as an organisational quality, it showed up as personal quality. That is to say that some people cared and showed their caring whereas others did not. Which suggests to that the organisation is not consciously, deliberately cultivating a culture of caring.

Now lets take a look at the business world, how do business organisations show care for their customers? Does care show up in the lives of customers? In what sense do customers feel cared for? What would show up if genuine care, for customers and their well being, was present? How would that effect product development, marketing, sales, customer service, logistics, finance…? Could it be that genuine care will work where all the shiny toys and fashionable tricks are not working?

And finally

I will conclude this series of posts by sharing with you the aspects of my ‘customer experience’ that were not so great and highlighting issues’/factors that need to be addressed.

Over the last four weeks or so I have touched and been touched by the ‘medical system’ in the UK – in particular my doctor’s medical practice and the NHS (national health service). I want to share with you the key insights that opened up for me on people and organisations.

Women show up as being more caring than men

Women as a whole whether in the role of receptionist, ‘blood taker’, nurse, trainee nurse or doctor simply show up as being more caring. In their being and in their doing they transcend the merely functional – the task. They put their humanity into the encounter – they smile, they strike up a conversation beyond the merely functional, they reassure, they do more than is necessary. The men, as a whole, focussed on their area of expertise and the task at hand. They are distant. They stand farther away (afraid to get close), they don’t smile, they are matter of fact, they focus on the task, time is clearly of the essence as they are keen to move on to the next person, the next job. There are exceptions. One female receptionist was particularly cold, clinical and showed up as being disconnected from even a thread of humanity. On the other hand Dr Jeremy Platt is almost always smiles and greets me warmly and takes the time that is necessary.

Insight. If we genuinely want our organisations to ‘touch’ our customers so that we show up as caring and thus create a space for emotional bonds to show up and form then this challenge has to be addressed. Men, as a whole, are one dimensional – functional. Either they are emotionally illiterate – that is to say that they are not in touch with their caring emotions or the cultures/communities they are embedded in do not give them permission to express their caring emotions. I suspect it is combination of these two factor – their is a lack of permission to show caring as this shows up as ‘soft’ and over time men lose touch with these soft emotions.

Question/Challenge. If the Tops got to the top by being ‘macho’ and ‘functional’ then how likely is it that these people will undergo a transformation and embody the softer emotions, values and associated practices which are the key to showing up as caring? Perhaps they will take the Steve Jobs approach – build that caring into the product. Or they will take the Amazon approach: build that ‘caring’ tone into the design of the operations. Yet, these approaches are not enough in services heavy industries where people (the employees) are the product, the experience and there is intimate contact between the customer and the employees.

The people on the front line can show up as ‘robotic’ and ‘inhuman’ because they perceive themselves to be powerless

I turn up at the scheduled 8am appointment for the endoscopy. Pain is present – that is the reason that I am there, to figure out what is the cause of the pain. The nurse ‘sells’ me on taking the right course of action – taking the sedative as it will relax me. I agree, I tell her I am in pain and so the sedative is the right way to go. Then she asks me who will be coming to pick me up and take me home. I tell her that my wife cannot pick me up until 3pm and that if I am well enough to go home earlier then I plan to use my favourite taxi firm to get me home. She responds by saying that she cannot offer me a sedative unless I have a family member to take me home and look after me for the next 24 hours – that is the hospital policy. I say “If you are not going to give me a sedative then you are not going to give me sedative. I am ok with that.” Except that I am not really OK with that.

Later the Consultant- the specialist who is going to do the endoscopy – comes to see me with the nurse trailing behind. He asks me some questions, I answer. Then he asks me why I have chosen not to have the sedative. I tell him that I want the sedative and I have been told that I cannot have it. And I tell him the reasoning. He tells the nurse that he will be giving me the sedative as that is the right course of action given the pain I am in and the procedure involved. He tells her to find me a bed.

Instantly the whole being of the nurse changes. It is clear that ‘God’ has spoken and his command must be obeyed without question, no excuse will suffice. She tells the doctor that she will ring around several wards and that she is confident that she can find me a bed in a specific ward. There is no doubt in her voice, absolute confidence. She leaves and several minutes later she comes back and tells me that she has found a bed for me. I am amazed at the instant/profound change in this nurse. It occurs to me that she is happy/proud at what she has accomplished; she has a big smile on her face and her tone of voice is different.

What is going on here? For the better part of 20 minutes or so this nurse showed up as robotic – going through the motions, following the script and preaching policy, ignoring my needs and the right thing to do, even changing her advice 180 degrees. Then the Consultant shows up, tells her what she needs to do and instantly there is a new human being in front of me: confident-resourceful-helpful as opposed to helpless and robotic.

What made the difference? I say she was given permission from THE authority figure to bypass policy and put her knowledge, her resourcefulness, her caring into action. I say that the Consultant showed up and instantly changed the context from which the nurse was operating from: from be a good robot/ follow the script/procedure to here is challenge/make it happen. Furthermore, the nurse was absolved from responsibility and blame – she was simply following orders. Which reminds of the Miligram experiments in obedience to authority.

Insight. When we look at poorly performing front line employees the tendency of managers, management consultants and the training industry is to assume that the fault, the deficiency, lies in the front line employees. In short we have an automatic bias. This reminds me of the story of the drunk looking for his lost car keys under the street lamp when he had lost them somewhere else. The smarter place to start looking for performance issues is in the context/the environment/the ‘system’ in which the front line employees are embedded and operating from. That means facing the reality: in about 95% of cases ‘poor employee performance’ shows up because it is the natural, inevitable, result of the assumptions/prejudices of the Tops and the ‘system’ that they have designed, actively or passively, to cater for those assumptions/prejudices. Let me put it bluntly, if you want to drive up performance and the customer experience then focus on the managers, the management style, the organisation design. That is where the real leverage is for step changes in organisational performance, customer experience and customer loyalty.

And finally

I will continue to share my insight with you in the follow up post – part II will be coming soon. If you are up for it then I’d love to hear your thoughts.

Some of you have been kind enough to enter into a conversation with me by commenting. You will have found me wanting – I have been lax in responding to your comments. I ask for your forgiveness, my excuse if there is one is simply that the last four weeks or so have been a struggle: the body, my health is not showed up as being my own.